Chronic Pain Management and Midlevel Encroachment

[godfather091]

Resident here- So I'm having a discussion a few months ago with a chronic pain doc about my future plans as a generalist, and she opined that current residents need to 'strongly consider' doing a fellowship for "job security" with all the common arguments we've heard before. She mentioned her reasoning on why she chose pain, one of which implying being safe from mid level encroachment. Many of my co-residents are under the same impression. She mentioned "the long game": what will being a generalist look like in 15-20 years?

Well what will interventional pain look like in 15-20 years? Based on the CRNA lobby and trends in nurse anesthetist chronic pain management "fellowships", CRNAs appear to be coming for chronic pain. As I'm not in the field, I'm not able to speak to the extent of encroachment or how widespread this is (I'm under the impression it is very limited currently), but is the writing not on the wall?

AANA Chronic Pain Guidelines

"CRNAs may be members of a multidisciplinary pain management team, receive referrals from other clinicians, or serve as the sole providers of chronic pain management services"

TCU Pain management fellowship

In your opinion, am I just completely wrong about CRNAs in chronic pain management? Why wouldn't they try to get into it? With every trend in modern medicine and the watering down of expertise, why wouldn't CRNAs go after interventional pain?

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[Ready_User_1]

It's hard to say, but the consensus is do a fellowship if you really enjoy the day to day work the fellowship would offer. People have been trying to predict the trends for decades and still have no more of an idea now than they did then. Besides, if you manage your money correctly, 15-20 years is all you need to walk away comfortably.


I'm hearing of pretty decent generalist positions out there from our outgoing grads for the past few years... the biggest difference is being an employee vs. owner is dwindling.

 

[TheLoneWolf]

I practice anesthesia and interventional pain management, fellowship trained. Training was very heavily interventional but in a university true multidisciplinary treatment program.

CRNAs independently practicing interventional pain has been going on for a while now.

A lot of non fellowship trained anesthesiologists and physiatrists practicing only interventional pain. Some family doctors and emergency room physicians attend weekend courses and conferences for fluoro and ultrasound guided blocks then call themselves pain specialists. Some of these courses are physician only. Some are not. I remember as a resident attending a very large name national annual pain conference and attending a few of the cadaver lab courses. Side by side with PAs/NPs who after speaking with them, want interventional only practices in rural areas.

Even chiropractors and naturopaths are out practicing interventional pain with ultrasound and fluoroscopy, especially the regenerative medicine cash only stuff. Even know of someone who had left residency without finishing and just opened a pain clinic, state specific.

Not hard to buy or lease a c arm and ultrasound machine.

No they are not only doing minor blocks. Some are out doing radiofrequency ablations and spinal cord stimulators.

I have worked in private practice with non fellowship trained physicians with a background in emergency medicine, family medicine, anesthesia, physiatry, and psychiatry. From my experience, the most knowledgeable and multidisciplinary focused are the psychiatrists.
The joke that pain management is really just interventional psychiatry is mostly true.

Overgeneralizing but many of the nonacademic anesthesia and physiatry guys just wanna go out after training and run a block shop. Again overgeneralizing, many of the family med and emergency medicine guys have little to no foundational understanding of the very basics of chronic pain or management. Many frequently tout disproven theories and treatments or experimental treatments on a cash only basis. Nothing is stopping a family doc from buying bone marrow aspiration kits, a centrifuge, and opening up shop. Nothing is stopping a new grad from opening up a ketamine clinic that claims to cure anything under the sun. Some pain docs used to overtest every urine sample with their own lab and found this is far more lucrative than interventional procedures. These "pee mills" really gave insurances a tough time. Now the DEA is cracking down hard on such behaviors. Heck, even dermatologists are pushing PRP and microRFA for many conditions. All real examples. Not trying to start a flame war, just my experience.

I'm not writing this to discourage you if you want to pursue this path but know that it's a wide open mostly unregulated market and many people from all sorts of educational backgrounds want a piece of the pain management pie.

The current pain market is saturated. Unless you want to go to the underserved boonies, it will be hard to open something for yourself.

Reimbursement has been dropping. Likely from over utilization. Even one of the biggest names in spinal cord stimulation is says it's way overused and may not be a covered benefit in the future if changes aren't made.

Some insurance companies will only allow you to bill for pain procedures if you are fellowship trained.

 

[GassYous]

All I know is that there are a bunch of people who are pain trained and doing mostly general anesthesia so...

The market for general anesthesiologists is pretty open atm. Lots of places offering shorter tracks, 6 figure signing bonuses etc. I had a bunch of attendings tell me to do a fellowship and I really thought hard about cardiac vs pain. I don't do either now although my practice does a lot of blocks and I'm pretty satisfied atm.